Committee Membership Form

Thank you for considering joining either the Braille Committee, Diabetic Committee, or the Guide Dog Committee of the National Federation of the Blind of New Jersey.

For more information about the Braille Committee, please visit https://www.nfbnj.org/projects/braille-committee or contact Mary Jo Partyka, Chair, at 609-888-5459.

For more information about the Diabetic Committee, please visit https://www.nfbnj.org/projects/blind-diabetics or contact Ed Godfrey, Chair, at 856-628-3657, or Angela Perone, Co-Chair, at 848-209-9465.

For more information about the Guide Dog Committee, please visit https://www.nfbnj.org/projects/guide-dog-committee or contact Brianna Murray, Chair, at 843-860-7625.

This form can only be submitted for residents of New Jersey and are current dues paying members of the National Federation of the Blind of New Jersey to one of its chapters and/or divisions. If you are not a resident of New Jersey, then you will not be able to submit this form.

Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Email*
Enter Email Confirm Email
*
I understand that this membership form is for the National Federation of the Blind of New Jersey's Braille Committee, Diabetic Committee, and/or Guide Dog Committee.
Membership Status*
Are you a current dues paying member of a National Federation of the Blind of New Jersey chapter and/or division?*
I want to join the following NFBNJ Committee(s)*
Select all that apply
- Braille Committee
- Diabetic Committee
- Guide Dog Committee
Are you blind/vision impaired?*
Are you a parent of a blind child?*
Are you a blind parent?*
Are you a blindness professional?*
Please designate which area of profession you work in*
- Orientation & Mobility Instructor
- Teacher of Blind Students
- Rehabilitation Instructor
Are you a guide dog user?*
Do you use a white mobility cane?*
Date of Birth
Prefered Media Format*
This information is for the NFB national office's information only for the Connections database.
Prefered Contact Method*